Background Informat Information for Trachy Competencies

7/30/2019 Background Informat Information for Trachy Competencies

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TRACHEOSTOMYTRAINING RESOURCES

A guide to tracheostomy management in Critical Care

and beyond.

August 2010

North West Regional Tracheostomy Group


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www.tracheostomy.org.uk

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Introduction

This guide is a resource for tracheostomy training and management in the critical care

setting and also beyond, on the wards and outpatient settings.

Included are descriptions of

What a tracheostomy is

How and why a tracheostomy can be formed

Different types of tracheostomy and tubes

Emergency management of the patient with a tracheostomy

Management of the day-to-day needs of the patient with a tracheostomy

Suggested infrastructure and resources for immediate and ongoing care of the

tracheostomy patient.

You are welcome to use and adapt these resources as you wish. They are not intended to

replace existing care pathways in your own institution, but you may wish to include some of

the material in your own unit or wards policies.

There are also separate resources available covering

Competencies for tracheostomy care and management

The authors do not accept any responsibility for any loss of or damage arising from actions

or decisions based on the information contained within this publication.

Ultimate responsibility for the treatment of patients and interpretation of the published

material lies with the medical practitioner. The opinions expressed are those of the authors

and the inclusion in this publication of material relating to a particular product or method

does not amount to an endorsement of its value, quality, or the claims made by its

manufacturer.


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Tracheostomies in critical care and beyond

Tracheostomies are common procedures in critical care practice but are also becoming morecommonplace on the general wards of the hospital. This is due to a number of reasons which

include the use of tracheostomy to provide respiratory support and airway toilet for certain

chronic respiratory and neurological conditions. However, temporary tracheostomy has

been recognized as beneficial in a number of patient groups in critical care and has become

increasingly common, particularly as bedside techniques mean that the procedure can be

performed simply, quickly and relatively safely. When combined with pressure on intensive

care beds and the increasing drive to de-escalate care quickly, increasing numbers of

patients with tracheostomies are being cared for on wards outside the critical care

infrastructure.

This has implications for the safety of patients who may be cared for on wards without thenecessary competencies and experience to manage this challenging cohort and local

measures need to be in place to ensure that safe routine and emergency care can be

provided. This guide has evolved to provide information to those caring for patients with

temporary or permanent tracheostomies either regularly or occasionally. It aims to provide

basic background information and the rationale for tracheostomy care. We have also

developed simple emergency guidelines for dealing with tracheostomy emergencies both in

critical care and beyond.


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What is a tracheostomy?

A tracheostomy is an artificial opening made into the trachea through the neck. This may be

temporary or permanent. A tracheostomy tube is usually inserted, providing a patent

opening. The tube enables air flow to enter the trachea and lungs directly, bypassing thenose, pharynx and larynx.

Diagram of larynx and trachea illustrating tracheostomy tube insertion sites.

Indications for a tracheostomy

To secure and clear the airway in upper respiratory tract obstruction (actual orpotential).

To facilitate the removal of bronchial secretions.

Laryngeal incompetence and aspiration on swallowing.

Poor cough effort with sputum retention.

To protect the airway of patients who are at high risk of aspiration, that is patients with

poor laryngeal and tongue movement on swallowing e.g. neuromuscular disorders,

unconsciousness, head injuries, stroke etc.

To enable long-term mechanical ventilation of patients in an acute ICU setting.

To facilitate weaning from artificial ventilation in acute respiratory failure and prolonged

ventilation.

To secure and maintain a safe airway in patients with injuries to the face, head or neck

and following certain types of surgery to the head and neck.


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Physiological changes with a tracheostomy

The upper airway anatomical dead space can be reduced by up to 50%, which improves

ventilation to the lungs.

The natural warming, humidification and filtering of air that usually takes place in the

upper airway is lost.

The patient's ability to speak is removed.

The ability to swallow is adversely affected.

Sense of taste and smell can be lost.

The tracheostomy will generally remain until the indication for insertion has resolved. In

some instances however, the tracheostomy will be permanent and these patients will be

discharged from critical care to a general medical or surgical ward.

Tracheostomy or laryngectomy?

The distinction here is critically important, but the appearance from the end of the bed can

be very similar for patients with a tracheostomy or a laryngectomy. A tracheotomy is

correctly a surgical opening in the trachea. This can be developed into a temporary or

permanent stoma (tracheostomy) or by removing the larynx, a laryngectomy. Importantly,

the patient with a tracheostomy has a potentially patent upper airway as an alternative

means of ventilating and oxygenating if the tracheostomy should become blocked or

displaced. A patient who has had a laryngectomy does not have any communication

between the upper airways (nose, mouth, pharynx) and the lungs and can only be

oxygenated and ventilated via the laryngectomy opening (which is the cut ends of the

trachea sutured onto the skin). Laryngectomy is shown on the left figure below, compared

with a standard tracheostomy on the right.


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Types of tracheostomy

Tracheostomy may be temporary or long term/permanent, and may be formed electively or

as an emergency procedure. They may also be classified by their method of initial insertion

either surgical or percutaneous.

Temporary will be formed when patients require long/short term respiratory support or

cannot maintain the patency of their own airway. Certain maxillofacial or ENT surgical

procedures require a temporary tracheostomy to facilitate the procedure. These tubes will

be removed when the patient recovers.

Long term/permanent are usually formed due to carcinoma of the nasooropharynx or

larynx. Dependent on the stage of the disease either a tracheostomy or a laryngectomy will

be performed. These patients are generally cared for in a specialist ward such as

maxillofacial or ENT units.

Some patients need chronic respiratory support or long term airway protection and this

requires a long term/permanent tracheostomy. For example, progressive neurological

conditions, insufficient respiratory capacity to breathe without support.


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The anatomic al posit ion o f a tracheostom y tube

Techniques for inserting a tracheostomyThere are two main techniques used to perform a tracheostomy: surgical or percutaneous

Surgical tracheostomy

This technique is usually carried out in an operating theatre where conditions are sterile and

lighting is good. General anaesthesia is generally used however this technique can also be

carried out with a local anaesthetic. A surgical opening is made into the trachea into which a

tube is placed; this may then be sutured to the skin or secured with cloth ties or a holder.

Surgical tracheostomies may be formed as part of ENT or Maxillofacial surgical procedures,

usually during face and neck dissections for tumour removal. Importantly, these procedures

may involve removal of the larynx which means that there is no connection from the mouth

or nose to the trachea. Using the tracheostomy is the only way of ventilating these patients.

Types of surgical tracheostomy

The tissues around the trachea are dissected and then the trachea is entered by making an

incision in its anterior wall. This may be one of the following:


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T-shaped tracheal opening through the membrane between the second and third or third

and fourth tracheal rings. With this incision, a silk stay suture can be placed through the

tracheal wall on each side and taped to the neck skin on either side. This facilitates tube

replacement by pulling the trachea anteriorly and widening the opening should the tube

dislodge in the immediate postoperative period. These sutures are removed after the first

tracheostomy tube change 5-7 days postoperatively once the newly formed tract from theskin to the trachea becomes more established.

U- or H-shaped tracheal opening can be made and the tracheal flaps can be tacked to skin

edges with absorbable sutures to create a semi-permanent stoma. Sutures can be placed in

each tracheal flap and taped to the chest and neck skin, facilitating replacement of a

displaced tube in postoperative care. Pulling on these sutures widens the tracheal opening.

Most modern surgical tracheostomies will be of this type with the sutures remaining for

approximately 1 week until the tract is formed.

Removal of small anterior portions of the tracheal rings can create a more permanent

stoma. A different type of surgical tracheostomy is the Bjrk flap where a ramp of trachea

is sutured to the skin which allows easier replacement of tracheostomy tubes. There may bea suture to the skin here too, but this is to hold the ramp in place, rather than to be used to

elevate the trachea for a tracheostomy tube change. See the figures below.

Percutaneous tracheostomy

This is the most commonly used technique in critical care as it is simple and quick, can be

performed at the bedside using anaesthetic sedation and local anaesthetic, and therefore is

Above: Different types of tracheal incision. The right-hand figure shows a tracheal flap.

Far left figure: Bjrk Flap

with a flap suture to the

skin (blue)

Right figure: Slit-type

tracheostomy with 2 stay

sutures (blue) to the skin.

These can be used to

manipulate the trachea


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often the technique of choice in the critically ill. The procedure involves the insertion of a

needle through the neck into the trachea followed by a guide-wire through the needle. The

needle is removed and the tract made gradually larger by inserting a series of progressively

larger dilators over the wire until the stoma is large enough to fit a suitable tube (Seldinger

technique). This is then secured by cloth ties or a holder.

Types of tracheostomy tubesThe different types of tubes available can seem confusing. Essentially tubes can be described

by the presence or absence of a cuff at the end, by the presence or absence of an inner

cannula, or by the presence or absence of a hole or fenestration. Tubes can finally be made

of different materials and be different diameters and lengths.Not all tracheostomy or

laryngectomy stomas need a tube to be inserted into them. Established stomas will usually

not have a tube inserted into them unless the patient needs oxygen, regular suctioning,

respiratory support or protecting their lungs from aspiration.

It is essential that staff caring for a patient with a tracheostomy know the type of tube

in place at any time, and this should be clearly documented in the patients notes. We

also advocate bed head signs clearly displaying immediate information about the

tracheostomy and tube for emergency situations.

Cuffed Tubes

Cuffed tubes have a soft balloon around the distal end of the tube which inflates to seal the

airway. Cuffed tubes are necessary when positive pressure ventilation is required or in

situations where airway protection is essential to minimize aspiration of oral or gastricsecretions (although all cuffs are not an absolute barrier to secretions).

If the tracheostomy tube lumen is occluded when the cuff is inflated, the patient will not

be able to breathe. In this situation, it is important to deflate the cuff and call for

medical assistance immediately.

Cuffed Tube (un-fenestrated)


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Un-cuffed Tubes

Uncuffed tubes do not have a cuff that can be inflated inside the trachea and tend to be

used in longer-term patients who require ongoing suction to clear secretions. These tubes

will not allow sustained effective positive pressure ventilation as the gas will escape above

the tracheostomy tube. It is essential that patients have an effective cough and gag reflex to

protect them from aspiration. Un-cuffed tubes are rarely used in acute care.

Fenestrated Tubes

Fenestrated tubes have an opening(s) on the outer cannula, which allows air to pass through

the patient's oral/nasal pharynx as well as the tracheal opening. The air movement allowsthe patient to speak and produces a more effective cough. However, the fenestrations

increase the risk of oral or gastric contents entering the lungs. It is therefore essential that

patients who are at high risk of aspiration or on positive pressure ventilation do not have a

fenestrated tube, unless a non-fenestrated inner cannula is used to block off the

fenestrations (see figures below).

Suctioning with a fenestrated tube should only be performed with the non-fenestrated

inner cannula in situ, to ensure correct guidance of the suction catheter into the trachea.

Un-cuffed, fenestrated tube.

These tubes allow much more air flow to the pharynx. The fenestration (hole) can be

occluded with appropriate inner tube. These tubes are common in patients discharged from

critical care.

Un-cuffed tube (Un-fenestrated)

Most air flows to lungs. Some leaks past tube into

pharynx and mouth.


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Any patient transferred from Critical Care to a ward should have the cuffed un-fenestrated

tube changed for a double lumen un-cuffed tube, which may be fenestrated depending on

local policy and on patient factors. This allows easy cleaning of the inner tube on the ward

and helps prevent blockage of the tracheostomy with secretions. (ICS & NPSA Guidance

2008/9).

The inner tube should be removed and cleaned in sterile water every 6 hours, and kept in

a clean container at the patient bedside when not in use.

Single Cannula Tubes

Single cannula tubes are traditionally the first tube to be sited in a critical care area. The

system is less complicated than a double cannula tube and is usually for temporary use only.

These tubes can be cuffed or uncuffed. The larger inner diameter of the single cannula tube

allows pressure support ventilation when the cuff is inflated to form a seal within the

trachea. The Intensive Care Society in their 2008 guidance have recommended that these

tubes are not used routinely in critical care owing mainly to concerns about them becoming

occluded with secretions, and the difficulty in cleaning this type of tube.

Double Cannula Tubes

Double cannula tubes have an outer cannula to keep the airway open and an inner cannula

which acts as a removable liner to facilitate cleaning of impacted secretions. Some inner

cannula are disposable, others must be cleaned and re-inserted. Patients discharged from a

critical care area with a tracheostomy should have a double un-cuffed cannula in place. This

type of tube is the safest to use outside the critical care environment, although to reduce

the incidence of tube occlusion, the inner cannula must be regularly cleaned.

Un-cuffed fenestrated tube


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The figure below shows two types of inner tube included with the un-cuffed tube, along with

the blocking tube which can be used for insertion of the tracheostomy only. This blocking

tube must be removed once the tracheostomy is sited.

The upper inner tube has no hole (or fenestration) and so air flow is allowed straight through

the tube from one open end to the other. When this is in situ, minimal amounts of air pass

through the patients upper airway. This inner tube should be in place when the patient is

suctionedas there is a small risk of a suction catheter passing through the fenestration and

damaging the tracheal mucosa.

The lower type of inner tube has a fenestration in it, which lines up with the fenestration in

the outer tube. Air can then flow through the tube as before, but in addition, some air can

flow through the holes and out through the patients mouth. This air flow to the upper

airway allows the patient to talk.

If positive pressure needs to be given to the patient to aid ventilation, for example in the

event of a cardiac arrest or worsening respiratory function, then the tracheostomy inner

tube without the fenestrations should be fitted, this then allows positive pressure airflow toenter the lungs rather than escaping through the mouth.

Adjustable Flange Tracheostomy Tubes

These tubes are used in patients who have an abnormally large distance from their skin to

their trachea, and a standard tube would not fit properly. Approximately 1/3 of critical care

patients may require these types of tubes. Particular indications are:

Patients with very large neck girth including the obese

Oedema caused burns classically or a capillary leak syndrome (sepsis etc)

Actual or anticipated oedema after surgical procedures (including tracheostomyitself)

Inner tubes. Lower tube

has a fenestration

Un-cuffed, fenestrated

outer tube


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It is essential to review the position of the flange (hence the length of the tube) on a daily

basis. If the patient has neck swelling, the as this worsens or resolves, the flange may need

adjusting. Adjustable flange tracheostomy tubes can now be used with removable inner

cannulae.

Mini Tracheostomy

A mini tracheostomy involves the insertion of a small 4 mm non-cuffed tracheostomy tube

through the cricothyroid membrane. This

can be done under local anaesthesia. It is

primarily inserted to facilitate the removal

of secretions. It does not protect the

airway from aspiration and will only

provide a route for oxygenation in the

emergency situation.

Adjustable

flange

Depth

insertion

markers


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Choice of tracheostomy tube

The Intensive Care Society produced guidance on tracheostomy care in 2008 which included

information on the choice of tracheostomy tube. This is summarised below.

An important consideration is whether to use a tracheostomy with an inner tube from thetime of initial percutaneous tracheostomy which may be done for weaning on the ITU. It is

increasingly recognised that tube obstruction can occur in critical care areas as well as on

the wards and the ICS recommend that these easily cleanable tubes should be used where

possible as standard to reduce the risks of obstruction. The disadvantage is that these tubes

have a reduced internal diameter which has implications for gas flow. This has to balanced

against the increased risks of tracheostomy tube obstruction with single lumen tubes, and

the 3-5 (ideally 7-10) days that a tracheostomy tube should not be changed for after a

percutaneous procedure if the patient is to be moved to a non critical care area.

Factors influencing temporary tracheostomy tube choice (ICS 2008)

Respiratory function

Most temporary tracheostomies will be inserted whilst a patient is in an intensive care unit

and still requiring some degree of positive pressure ventilation. As a standard, this will

require the use of a cuffed tracheostomy tube (although it is recognised that

long term mechanical ventilation can be delivered through an uncuffed tube).

Abnormal airway anatomy

Upper airway endoscopy following percutaneous insertion suggests that a standard

tracheostomy tube may be anatomically unsuitable in as many as a third of adult patients.

Obese patients may require a tube with an extended proximal length, whilstpatients with fixed flexion abnormalities may not easily accommodate tubes with a fixed

angulation. Airway pathology Localised airway pathology such as tracheomalacia, granuloma

formation etc may on occasion necessitate the use of a

tracheostomy tube that has a longer distal length than standard.

Compromised airway, protection and weaning problems

Many patients can be weaned to decannulation without any need to change to change from

the cuffed tracheostomy tube that was initially inserted. In problematic cases however, it

may be useful to consider options such as downsizing, to an uncuffed or fenestrated tube, or

a tube with the option for sub-glottic aspiration of airway secretions. The introduction of a

speaking valve may also aid swallowing and secretion control.

Obstructed / absent upper airway

Patients with an obstructed or absent upper airway are at particular risk should a

tracheostomy become obstructed or misplaced. This has implications for both the choice of

tracheostomy tube as well as the method by which the stoma is

fashioned.

Clinical environment

Obstruction of a cuffed tracheostomy tube is a potentially life threatening emergency.

Wherever possible a dual cannula tube (i.e. a tube with an inner cannula) should be used,

particularly for patients in HDU or ward environments who may not have immediate access


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to clinicians with emergency airway skills. Ward staff can change inner tubes easily and

quickly to relieve obstruction with secretions.

Complications of a tracheostomy

Once a tracheostomy tube is sited for airway management the patient should be observed

for the following potential complications. These can be serious and sometimes fatal. These

complications are usually grouped as follows:

1.Immediate Complications (peri-operative period)

Haemorrhage (usually minor, can be severe if thyroid or blood vessels damaged).

Misplacement of tube - within tissues around trachea or to main bronchus.

Pneumothorax.

Tube occlusion.

Surgical emphysema.

2.Delayed Complications (post-operative period < 7 days)

Tube blockage with secretions or blood. May be sudden or gradual.

Partial or complete tube displacement.

Infection of the stoma site.

Infection of the bronchial tree (pneumonia).

Ulceration, and/or necrosis of trachea.

Mucosal ulceration by tube migration (due to loose tapes or patient intervention).

Risk of occlusion of the tracheostomy tube in obese or fatigued patients who have

difficulty extending their neck.

Tracheo-oesophageal fistula formation.

3.Late Complications (late post-operative period >7 days)

Granulomata of the trachea may cause respiratory difficulty when the tracheostomy

tube is removed.

Tracheal dilation, stenosis, persistent sinus or collapse (tracheomalacia)

Scar formation-requiring revision.

Blocked tubes may occur at any time, especially if secretions become thick, the

secretions are not managed appropriately (suction) and humidification is not used.


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Potential problems post placement

Blocked Tracheostomy

One role of the upper airway is to moisten and warm inhaled air before it reaches the lungs.

Cilia are small hair like protrusions that line the respiratory tract; the function of the cilia is

to prevent infection within the respiratory tract by moving mucus and other particles away

from the lungs.

Inserting a tracheostomy tube bypasses these natural mechanisms, which mean the lungs

will receive cool, dry air. Dry air entering the lungs may reduce the motility of the secretions

within the lungs and may reduce the function of the cilia. In addition the patient may not be

able to cough and/or clear the secretions from their airways through the tracheostomy. This

may cause the tracheostomy to become blocked by these thick or dry secretions.

Blocked tracheostomy tubes can be minimised by careful humidification, tracheal suction

and inner tube care. However it is necessary to keep emergency equipment at hand at all

times as a blocked tube may lead to respiratory arrest.

Pneumonia

A build up of secretions may also lead to consolidation and lung collapse, and this may lead

to pneumonia. This can also be minimised by careful humidification, tracheal suction and

inner tube care.

Aspiration of gastric contents may also lead to pneumonia. This can occur with patients who

are unable to swallow safely. Any patient who you suspect may have aspirated will need to

have a SALT (Speech And Language Team) assessment, be kept NBM and referred to a

dietician to facilitate NG feeding.

Displaced Tracheostomy Tube

The tracheostomy tube can be displaced partially or completely and come out of the stoma

or out of the trachea into the soft tissue of the neck. If not properly secured, the tube may

become displaced by coughing, because of its weight or the weight of attached breathing

circuits, or by patient interference. Partial tube displacement is more dangerous as it is not

always visibly obvious that the tracheostomy is not patent.

In order to keep tracheostomy tubes in position they must be secured carefully and any

concerns raised by the patient or nursing staff must be promptly investigated.

Red Flags such be acted upon as they may herald actual or imminent tracheostomy tube

displacement. Prompt assessment by a senior clinician is required and a fibre-optic inspect

of the position of the tracheostomy tube tip to confirm correct placement within the trachea

is usually indicated. Red flags include:

Increasing ventilator support or increasing oxygen requirements

Respiratory distress

The patient suddenly being able to talk (implying gas escaping proximally and thecuff no longer sealing the trachea)


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Frequent requirement for (excessive) inflation of the cuff to prevent air leak

Pain at the tracheostomy site

Surgical (subcutaneous) emphysema (gas in the soft tissues)

The patient complaining that they cannot breathe or have difficulties in breathing

A suction catheter not passing easily into the trachea A changing, inadequate or absent capnograph trace

Suspicion of aspiration (feed aspirated on tracheal toilet suggests that the cuff is

not functioning adequately)

Local Infection

There is a risk of site infection caused by introduction of organisms from the sputum. Careful

observation and dressing of the site will reduce this. A stoma should be treated as a surgical

wound and cared for appropriately.

As the stoma is an open wound opening directly into the respiratory tract there is potential

for the lower respiratory tract to become infected. Poor suction technique may also

increase the incidence of infection.

Tracheal Damage/IschaemiaDamage to the trachea may be caused by cuff pressure on the mucosa or by poor tracheal

suctioning techniques. All tracheostomy tubes now have low pressure cuffs, however over-

inflation should still be avoided. The pressure in the cuff should be just adequate to prevent

air leakage.

Altered Body Image

This is an important factor as it can have a major psychological impact. If possible the patient

should have careful pre-operative explanation. If this is not possible the patient must receive

explanation and support post-operatively.

Inform the patient that scarring will be minimal when the tracheostomy is removed and the

stoma has healed and, that speech will return (as long as the vocal cords remain intact). On

average the stoma will close and heal within 4-6 weeks. However this may vary from patient

to patient depending on factors affecting wound healing.

Communication

Patients with a cuffed tracheostomy will be unable to speak; loss of speech whilst thetracheostomy is in place could possibly cause great distress to the patient, even if he/she has

warning beforehand. It can cause fear, because of inability to attract attention if needed or

depression because of inability to communicate (even with the cuff down).

Generally patients who have an un-cuffed tube or the cuff deflated will be able to speak with

a speaking valve in place.

Communication aids such as pen / paper or picture cards are vital to prevent the patient

feeling frightened and isolated. In addition ensure the patient has a nurse call bell at all

times.


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Speaking valves

These are one-way valves that fit over the end of the tracheostomy. They allow the patient

to breathe in through the tracheostomy, but not out. The air flow has to go up through the

larynx and out of the mouth. This can allow the patient to talk, but can be tiring for the

patient due to increased resistance to airflow.

Because air cannot flow out through the tracheostomy, these valves can be extremely

dangerous. They are increasingly used in controlled critical care settings as the patient

weans from ventilator support to allow training of the larynx and to increase the work of

breathing as the patients recover from critical illness.

Speaking valves should ideally be used with a fenestrated tube and only when the

fenestrated inner cannula is in place. Any cuff must be deflated.


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Emergency management of the

patient with a tracheostomy

Tracheostomies are common in ENT and Max Fax surgical procedures and are increasingly

used in Critical Care. This means that tracheostomies are more frequently on general

wards. Managing patients with a tracheostomy can be challenging if unfamiliar and disasters

can (and do) happen if emergencies occur.

Common emergencies include

Obstructed tubes

Completely dislodged

Partially dislodged

Laryngectomy patients can also be very confusing for those unfamiliar with the anatomical

steps involved in removing a patients larynx. It is important to understand the differences

between those patients who do and dont have a larynx after a tracheostomy, and this is

explained in the next section.

We have suggested an algorithm for the emergency management of patients with a

tracheostomy who develop breathing difficulties. It is designed to be simple and is aimed at

first responders to the patient who may be Medical, Nursing or Allied health staff.

We have made recommendations for airway experts in the following section which should

include critical care and anaesthetic doctors who are experienced enough to work at ST 3

level and above.

The guideline includes

Steps and interventions to maintain oxygenation & ventilation

Prepare patient for advanced interventions

The guidance is applicable to the patients with

A tracheostomy (surgical or percutaneous)

Recently decannulated (trachy removed)

Laryngectomy

Any breathing difficulties

There are some more advanced options included for the attending Expert who will be

called early in the management of a tracheostomy patient with breathing difficulties. You

can find presentations and videos describing the algorithms and why they are constructed in

the format we suggest atwww.tracheostomy.org.uk.
http://www.tracheostomy.org.uk/http://www.tracheostomy.org.uk/http://www.tracheostomy.org.uk/http://www.tracheostomy.org.uk/


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Symptoms of Respiratory Distress

The sort of patients that you will be called to see may show the following signs. Some of

these are detectable clinically and others will be noticed by monitors such as pulse oximetry,

Capnography and ECG. These may not all be in place in high dependency and ward

environments.

Apnoea

Difficulty in breathing observed or reported

Vocalisation (patient talking or whispering) when airflow should not be via the upper

airway (cuff up)

Increased respiratory rate

Increased heart rate

Low O2 saturations

Grunting, Snoring, Stridor

Whistling noise when breathing or any noisy breathing

Cyanosis (pale, blue colour around lips, nail beds, eyes)

Restlessness, Confusion, Agitation, Anxiety

Blood or blood stained secretions via the tracheostomy

Retractions (pulling in of the skin between the ribs, and below the breast bone,

above collar bones or in the hollow of the neck)

Increased discomfort reported by the patient

Cuff requires lots of air to remove air leaks

Any of the above clinical concerns should be considered as tracheostomy red flags and an

assessment of the tracheostomy should be carried out by someone competent to do so. This

is particularly important if the patient has any signs or symptoms suggesting that the

tracheostomy may be displaced, usually air leaks or vocalizations. A prompt fibre-optic

examination of the tube position is usually required and may allow the clinical situation tobe rectified before the tracheostomy becomes completely displaced or blocked.


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Why are there 2 algorithms?This is because of the potential problems posed by patients with a laryngectomy. It should

be clear from the bedside, handover and the patient notes that the patient has had a

laryngectomy. Suggested signs are included in the appendix to be displayed at the patient

bed head to make it clear what type of tracheostomy a patient has and whether they have a

laryngectomy or not.

Surgical laryngectomy

A laryngectomy is the surgical removal of the voice box. In this procedure the larynx is

removed and the trachea is sutured to the skin creating a permanent stoma.

A total laryngectomy involves the removal of the hyoid, all of the thyroid and cricoid

cartilages, and 1 or 2 tracheal rings. The overlying strap muscles are resected and the

supraglottic, glottic, and subglottic areas are removed. The resultant cut end of the trachea

is then sutured to the skin of the neck creating a permanent stoma.

The patient will then breathe through this stoma for the rest of their lives. There is no

connection between the oral/nasal passages and the trachea following the procedure.

This is obviously vital information as the only way of delivering oxygen (or any other gas) to

or from the patients lungs is via the stoma. Standard oral airway manoeuvres will not work

as there is no connection between the mouth, nose or pharynx and the lungs.


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Patent upper airway algorithm (No Laryngectomy)


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Explaining the algorithm patent upper airway

It is important to note that these patients may still have had a surgically performed

tracheostomy, but they still have their larynx intact. They may have had their tracheostomy

performed percutaneously it doesnt matter. The important thing is that there is still a

larynx and so a potentially patent upper airway to use in an emergency.

The initial response is firstly to apply 100% O2 to BOTH the face and the tracheostomy

stoma. This guidance is the same for those patients with and without a laryngectomy to

standardize the approach. Laryngectomy patients will get no benefit from facial oxygen, but

it will do no harm. First responders to an emergency situation may not understand this

however and there is a greater risk of NOT applying facial oxygen to a patient in whom it

may be critical. You will need 2 oxygen supplies one for the facemask and one for the

tracheostomy. This may need the use of an appropriate cylinder, perhaps on the emergency

trolley in ward environments.

Also within the initial response is a call for help to Anaesthetics or Critical care AND to ENT

or Max Fax surgical teams as appropriate. The Crash or cardiac arrest teams may also be

required, but they might not have the relevant skills regarding tracheostomy management.

A fibreoptic scope should also be requested urgently. Quite who is called will depend on the

patient location and local arrangements, but it is important to summon expert help urgently.

The next step is to make some assessment of the patency of the tracheostomy. The majority

of patients with tracheostomies will have a potentially patent and useable upper airway and

there is often some airflow past a tracheostomy, even with the tracheostomy tube still in

place or partially displaced. This may be detected as

Vocalisation

Misting on a face mask

Feeling breath

By using Capnography (CO2 detection, usually in Critical Care)

Airflow may be detected at the mouth or at the tracheostomy stoma. One of the easiest

ways of detecting the movement of air is by attaching a Waters circuit to the tracheostomy

tube and looking for evidence that the bag is moving. This does of course require a

spontaneously breathing patient, and the bag may not move if there is no respiratory effort

at this stage. We are going on the assess the patency of the tracheostomy here though andwill assess breathing more formally later in the algorithm.

In order to give ourselves the best chance of detecting the movement of air via the

tracheostomy if there is any present, we advocate inflating the cuff at this point, if there is

one present on the tube. This step is to aid in the assessment of the patency of the

tracheostomy tube. We will deflate the cuff shortly if the trachy tube is not patent, as an

inflated cuff may cause further problems if the tube is partially displaced (see section and

figure later).

In Critical Care areas, the use of Capnography can prove essential in deciding whether atracheostomy tube is patent or not. A consistent Capnography trace can only come from the


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lungs, implying at least partially correct placement of the tracheostomy tube, and

subsequent patency. Evidence would suggest that this is the most useful monitor when it

comes to deciding if a tube has become displaced. A partially displaced tube is more than

twice as likely to cause patient harm than a visibly obviously displaced tube, as the diagnosis

may not be as apparent.

If the patient is connected to a closed suction system or similar breathing circuit, then it is

usually a good idea to remove it from the tracheostomy at this point before connecting your

rescue breathing system (eg Waters circuit, see figure below). This removes any doubts

about the patency of this system which may itself have become blocked.

If there is no spontaneous breathing detected via the tracheostomy, we must assesswhether it is patent. This is best answered initially by whether you can pass a suction

catheter? A suction catheter should pass easily if the tube is in the trachea. If it does pass,

then you may need to perform suction of blood or sputum which may relieve the problem.

It is important to know how long your suction catheters are and how much dead space you

need to negotiate before entering the tracheostomy tube. This will depend on the type of

breathing circuit attached to the tracheostomy. The figure below demonstrates that with a

closed suction system attached and with the tracheostomy in various misplaced positions, it

is still possible to insert a suction catheter to about 17cms. Only easy passage of a catheter

beyond 17cms should be used to confirm patency of the tube. As stated above, the simplest

way of making you assessment is to remove all connections to the tracheostomy tube at thispoint.

Example of a capnograph trace

It is not a good idea to attempt vigorous

ventilation at this point via the tracheostomy.

There have been reports of partially displaced

tubes being ventilated and this has caused

significant and even fatal subcutaneous

emphysema.


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As can be seen from the figure below, an inflated cuff in the trachea may impede attempts

to oxygenate from above. The cuff was inflated to give us the best chance of assessing the

patency of the tracheostomy, but we have completed that step now. The only situation in

which deflating the cuff may worsen a situation is if there is active bleeding from the

tracheostomy stoma or trachea. The cuff may help to tamponade the bleeding point if it

remains inflated.

There is a small chance that the suction

catheter passes but not into the airway. The

catheter has passed into the soft tissues and

this is called a false passage. You will

reassess the breathing at this point and therewill be no improvement in ventilation or

evidence of spontaneous tracheostomy

breathing. In this case proceed down the

algorithm as suction has not improved the

situation.

The next step is to deflate the cuff again if

present. This is because we have now

established that the suction catheter will not

pass through the tube meaning it is either

blocked or displaced.

A partially displaced tube at this point is the most

dangerous situation. It may not be visibly obvious

and leaving the tube in situ, particularly with acuff inflated may be making the situation worse.

Another important point here is to check if a

double cannula tracheostomy is being used. If so,

remove, clean and replace the inner tube which

may be causing the obstruction.

It is important to replace the tube because some

designs of tracheostomy tube require the inner

tube to be in place to allow connection to a

breathing circuit. The tracheo-twist tubes are an

example of such tubes (Figure to the right).

As with any intervention, if you have done

something, you need to assess whether it has

helped. Returning and reassessing breathing is

mandatory at this point if an intervention has

been carried out.

Tracheo-twist tube. This inner tube needs to be

inserted to allow connection of a suitablebreathing circuit to the tracheostomy.


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Removing the tracheostomyIf none of the measures performed already cause the tube to become patent, it is either

Totally blocked

Totally displaced

Partially displaced

The tracheostomy tube MUST be removed at this point if the patient is continuing to

deteriorate. This may seem like a drastic step but as described above, it is currently offering

no assistance and may be making the situation worse. There have been incidents described

where the rescuers have continued to fruitlessly work on the tracheostomy when it is clearly

not going to help and neglected other basic life-saving maneuvers. The priorities are safe

management of the airway and adequate oxygenation.

If an airway expert is present AND safe, adequate oxygenation is occurring via the facial

route, then the expert may choose to attempt to manipulate the tracheostomy perhaps

using a fibre-optic scope or similar adjunct (see below). This may be particularly relevant for

a patient with a known difficult airway or tracheostomy. We have not recommended this for

junior staff at this stage.

What to do now you have removed the tracheostomy tubeFirstly you should cover the stoma with some sterile gauze or similar to minimize air leaks

and then proceed to manage the airway just like any other compromised airway. This will

depend on your skills and experience, but the important step is to oxygenate the patient. It

doesnt matter if you cant re-intubate them if they are safely oxygenating whilst expert help

arrives.

Standard oral airway maneuvers may include the use of a head tilt and chin lift, a jaw thrust

or use of adjuncts like oral or nasal airways. If your skills permit you, a Laryngeal Mask

Airway (LMA) can be useful here. The patient may need sedative drugs at this point, but only

do this if you are skilled to deal with managing the airway of an anaesthetised patient.

Whatever your level of experience, it is

important to prepare for the possibility of a

difficult airway and a difficult intubation. This isdue to airway trauma, oedema and bleeding

which may be associated with the tracheostomy

procedure or the underlying pathology.

Remember also that critically ill patients do not

have the same reserve as healthy ones and will

become cardiovascularly unstable and

desaturate more quickly than in health.

Guedel Oral Airways

Laryngeal Mask


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If you are intubating the patient, pass the tube beyond the stoma to seal it off (see figure).

Use an un-cut tube to allow this but pay

extra care that you havent passed the tube

too far into the left or right main bronchi

(endobronchial intubation). The ideal

situation is a stable, ventilating, oxygenating

patient. If this is achieved just by holding an

appropriate facemask, then thats fine! Get

someone to gather appropriate drugs and

equipment that may be used by an expert

for definitive management of the airway or

tracheostomy when they arrive.

What if you cant oxygenate using standard maneuvers?

Turn your attention back to the stoma. This is going to be the only route left to try and

oxygenate your patient. This is a very dire situation, but the following steps may help to

secure a means of oxygenating the patient. It is important to stress that if the patient is

adequately oxygenating, then the safest thing to do is to await an expert, but if the clinical

situation is deteriorating, then the following outlines the options available to you.

Attempt intubation of the stoma

This can be attempted using a 6.0 cuffed endotracheal tube or a new tracheostomy tube.

The reason for this choice is that it is likely to be readily available and familiar to non-

experts. Always use at least one size smaller tube than the one removed, so if the patient

had a 6.0 tracheostomy tube in situ, then use a 5.0 endotracheal tube instead. The same

goes for a new tracheostomy tube. Experts may be experienced in a particular technique

and may use different equipment here. Positioning the patient with a towel or pillow under

the shoulders to extend the neck will bring the trachea anteriorly and may help difficulties.

If you are experienced, then you may wish to consider using a Bougie / Aintree catheter /

Suction catheter as guide. A fibre-optic scope may give you a better idea of where you are

heading, but is not always as good as you might imagine, especially if there is tissue trauma

or bleeding.

Attach the tube to a Waters circuit or similar and assess for signs that the tube is in the

correct place. The gold standard for this is Capnography if available, but clinical detection

of breath sounds (spontaneous or on careful ventilation) should be possible. If there is

resistance to ventilation, it is essential to stop. You have probably caused a false passage and

further attempts will cause subcutaneous emphysema and worsen the situation.

Attempt ventilation via the stoma

If you cannot easily and safely intubate the stoma, then you may be able to oxygenate oreven ventilate via the stoma by applying either a small facemask or an LMA to the skin


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surrounding the stoma (not into the stoma). You may not get a very good seal, but this

technique may allow critical oxygenation of the patient.

Laryngectomy algorithm

The Algorithm is different in places for those patients who do not have a larynx as previously

explained. The initial steps are similar in calling for help and applying oxygen to the face and

stoma. Clearly, if those in attendance understand that applying facial oxygen is pointless in

this situation then it is not necessary. This step has been left in to ensure consistency when

managing the much more common emergencies with tracheostomies and a potentially

patent upper airway (ie no laryngectomy) as described in the previous section.

There may not always be a tracheostomy tube in the stoma to remove. You can still assess

the patency of the stoma by passing suction catheter however.

The algorithm is essentially the same until after the tracheostomy tube is removed. There is

now no point attempting oral maneuvers as there is no communication between the facial

upper airways and the lungs. Attention is turned straight to the stoma, as this is the only

method of oxygenating the patient.

The stoma is managed similarly to above by first attempting to oxygenate or ventilate by

applying a small face mask or LMA to the stoma. If this is unsuccessful, attempts at

intubation of the stoma should be attempted with either a small 6.0 endotracheal tube or a

tracheostomy tube as described above.

An expert may choose their own technique or be familiar with guides like a suction catheter,

Aintree catheter, Bougie, a minitrachesotomy or a fibre-optic scope.


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Options available to the airway expert

The algorithms above are designed for first responders who may be non-medical or non-

airway trained. They are thus designed to be simple and clear and allow safe initial

management of the compromised tracheostomy patient. They should address life

threatening situations in order and the focus is on oxygenation of the patient.

For the purposes of this guidance, an expert may be considered as an individual with

training and experience in advanced tracheostomy and airway management who will be

both confident and competent to manage these difficult situations. The standard will be that

of an ST 3 doctor in training (or above) in critical care or anaesthesia.

An expert will be called early in the algorithm. On their arrival, there will be one of three

situations

1. First responder has resolved the situation

a. Supportive intervention only

2. Stable patient oxygenating by face or stoma

a. May need sedation or anaesthetic to facilitate re-intubation or re-fashioning

of stoma

b. Non-emergency situation

3. A loss of airway crisis

The purpose of the emergency algorithm is to provide a standard approach to managing

respiratory difficulties in the tracheostomy patient. The key points are

1. Oxygenate by the oral and tracheostomy routes

2. Early removal of the tracheostomy if it is blocked, partially or completely dislodged

and the patient is deteriorating

3. Simple oral airway maneuvers

4. Appreciation that patients with a laryngectomy have no communication between

the face and the lungs

Maintaining oxygenation and ventilation by oral or tracheostomy routes may mean that you

encounter the patient in a stable condition and a decision about how to proceed in

managing the tracheostomy is required. These options would also be applicable in managing

the emergency situation with loss of the airway.

Several options are described below. Details of types of surgical tracheostomy are found in

the earlier chapters.

There is no right answer for these situations, and management will depend on your

experience and expertise, the clinical situation and the patient. This guideline aims to

provide details on the options that are available to you.

Decisions on whether to use sedation or paralysing agents again depend on your experience,and in your confidence in being able to manage an effective airway and adequately


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oxygenate and ventilate once spontaneous respiratory efforts have ceased. As a general

rule, if there is spontaneous ventilatory effort and the patient is safely oxygenating (by

mouth or via the tracheostomy stoma) then sedation and muscle relaxation should not be

given until skilled personnel and equipment are immediately available to manage the

airway. This may require a return to the anaesthetic room, critical care environment or

operating theatre. Once the patient is paralysed, then you must be able to ventilate the

patient yourself, which may prove difficult or impossible.

Manipulation of a surgical tracheostomy

There may be stay sutures present that allow the trachea to be

pulled more anteriorly and the opening in the trachea to be

made wider. This can help facilitate re-insertion of a

tracheostomy tube, particularly in the first 7-10 days after thestoma has been formed, as the tract will not have established

itself.

Remember not to pull on the suture holding down the ramp-

like flap of a Bjrk flap type tracheostomy as this will probably

just tear the flap and potentially worsen the situation. (See

figures on page 6).

Cautions with a percutaneous tracheostomy

As explained above, the tract from the opening in the trachea to the skin does not establish

itself fully until 7-10 days after formation. This is more likely with a percutaneous

tracheostomy as the tissues have only been stretched (dilated) as against cut in the case of a

surgical tracheostomy.

Practically, this means that once the tracheostomy tube has been removed, the tissues are

likely to spring back into place quickly and this is more likely to happen the newer the

tracheostomy is. Manufacturers do not recommend changing tracheostomy tubes for 7-10

days after a percutaneous tracheostomy for this reason, as the passage from the skin to the

trachea may be lost quickly. If this happens, manipulation of the tracheostomy under the

same conditions that it was inserted originally under is usually required, namely with the

upper airway controlled and bronchoscopic guidance to visualize the guide, catheter or

tracheostomy entering the trachea. Attempting blind placement may cause a false passage

and should be avoided.


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Advanced upper airway options

Depending on your skill and experience and the clinical situation, advanced airway

techniques may be required to manage the upper airway. A full description is beyond the

scope of this document. Whether to give sedative or paralysing drugs is a decision that

depends on your experience and confidence in managing the situation and airway onceconsciousness has been lost.

Options for the upper airway include

Alternative laryngoscope blades McCoy, Straight blades

Laryngeal Mask Airways Classic, Proseal, Intubating LMAs

Fibre-optic laryngoscopes Airtrach, McGrath, Glidescope

Fibre-optic endoscopes via the nose or oral routes

Aintree Catheters or similar

Blind placement of a tube, orally or nasally

Options for managing the stoma

If the upper airway cannot be managed safely, then attention will turn to the stoma. If the

patient is stable, then the stoma should be managed in a controlled situation and

environment if possible. This may necessitate a trip to theatre with an appropriate surgeon.

In an emergency, the following options are available.

Attempted ventilation of the stoma, as described in the previous section

Using a suction catheter (probably the least traumatic) an Aintree catheter (allowsoxygenation) or a gum-elastic bougie to try and enter the stoma. A tracheostomy

tube can be rail-roaded over the guide, but there is a risk of false passage creation

and incorrect placement. Capnography would be ideal here.

Blind placement of a small (6.0) endotracheal or tracheostomy tube.

Specialist tubes. There are tapered tubes available, or some tubes which come with

shaped introducers, as shown below.


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Management of the day-to-day

needs of the patient with a

tracheostomyThere should be a detailed plan of care for all patients with a tracheostomy. A suggested

care plan is provided as an appendix, but local policies may already be in place. The care plan

should be reviewed on a daily basis and updated if there is any change.The patient with a

tracheostomy needs diligent observation and assessment. The nurse caring for the patient is

responsible for this, seeking advice from other professionals as appropriate.

Patient assessmentAt the start of each shift the Staff Nurse caring for the patient with a tracheostomy should

carry out a full assessment of the patient which should include:

Why does the patient have a tracheostomy?

When was the tracheostomy performed? Was it surgical or percutaneous (may have

implications for ease of re-insertion) and does the patient have a larynx? (Ie do they

have a communication between the oral airway and the lungs?)

There may be information sheets available at the patients bed space to quickly and

easily communicate this information.

Type and size of tracheostomy tube & availability of spare & emergency equipment Sputum characteristics:

Colour

Volume

Consistency

Odour

Cough effort

Check inner cannula for any build up of secretions, and clean inner cannula.

Check tracheostomy holder is secure and clean

Check stoma dressing is clean

Ability to swallow, including any SALT assessments ( see section on Swallowing

assessment)

Routine Observations including:

Respiratory rate, pattern and skin colour

Oxygen saturations

Temperature

Breath sounds

Blood pressure & Heart Rate

Fluid balance

This assessment should be documented on the care plan at the start of every shift.


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SWALLOWING ASSESSMENT

The presence of a tracheostomy can compress the oesophagus, and makes swallowing

difficult for some patients, this increases the risk of aspiration. The risk is greatest in those

patients with associated neurological or mechanical causes of dysphagia, or those with

significant on-going respiratory failure. Some patients with a tracheostomy may experienceproblems with swallowing, whilst others may not. For psychological well being oral intake

may be permitted.

The decisions to allow feeding should be made on an individual patient basis. All patients

discharged to a general ward with a tracheostomy should be referred to Speech and

Language Therapy (SALT) for a swallow assessment and feeding recommendations will be

documented by the team on the ICP.

Risk factors for swallowing problems in patients with a tracheostomy

Aspiration has been reported in up to 85% of tracheostomy patients. Those most at risk are: Neurological injury

Disuse atrophy

Head & neck surgery

Signs of aspiration may include:

Evidence of aspiration of enteral feed or oral secretions on tracheal suctioning

Increased secretion load, or persistent wet / weak voice, when cuff is deflated

Coughing and / or desaturation following oral intake

Patient anxiety or distress during oral intake

Any patient that fails their swallow assessment must be given nutrition by another route;

this may be enteral or parenteral.

CHEST PHYSIOTHERAPY

All patients with a tracheostomy should be assessed at least daily, or more often depending

on individual patient need, by the chest physiotherapist.

HUMIDIFICATION It is mandatory that a method of artificial humidification is utilised when a

tracheostomy tube is in situ, for people requiring oxygen therapy - dry oxygen should never

be given to someone with a tracheostomy. The type of humidification will be dictated by the

needs of the patient. Advice may be sought from the Critical Care Outreach team and

physiotherapist. In normal breathing, inspired air is warmed, filtered and moistened by

ciliated epithelial cells in the nose and upper airways. However, these humidifying functionsare impaired by a tracheostomy tube and air inspired will be cold and dry (eg oxygen

therapy), due to the bodys natural mechanisms being bypassed. Inadequate humidification

can result in a number of physiological changes which can be serious to the patient, be

irreversible and potentially fatal, including: 27


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ired mucociliary transport

sed risk of bacterial infiltration.

As a result, humidification must be artificially supplemented to assist normal function and

facilitate secretion removal. Failure to adequately humidify could result in tube blockage as

secretions become dry and viscous, forming a crust around the tracheostomy. This can be

potentially life threatening.

Humidification

In normal breathing, inspired air is warmed, filtered and moistened by ciliated epithelial cells

in the nose and upper airways. However, these humidifying functions are impaired by a

tracheostomy tube and air inspired will be cold and dry (eg oxygen therapy), due to the

bodys natural mechanisms for warming/moistening inspired air being bypassed.

It is mandatory that a method of artificial humidification is utilised when a tracheostomy

tube is in situ, for people requiring oxygen therapy dry oxygen should never be given to

someone with a tracheostomy.

The type of humidification will be dictated by the needs of the patient.

Inadequate humidification can result in a number of physiological changes which can be

serious to the patient and potentially fatal, including:

Retention of viscous, tenacious secretions

Impaired mucociliary transport

Inflammatory changes and necrosis of epithelium

Impaired cilia activity

Destruction of cellular surface of airway causing inflammation, ulceration andbleeding)

Reduction in lung function (e.g. atelectasis/pneumonia)

Increased risk of bacterial infiltration.

As a result, humidification must be artificially supplemented to assist normal function and

facilitate secretion removal.

Failure to adequately humidify could result in tube blockage as secretions become dry and

viscous, forming a crust around the tracheostomy.


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Methods of artificial humidification

Heated Humidification

Heated Humidification operates actively by increasing the heat and water vapourcontent of inspired gas, so that gas is delivered fully saturated at core temperature.

It is indicated for tracheostomy patients requiring mechanical ventilation or oxygen

therapy for 96 hours.

Cold Humidification

Cold humidification bubbles gas through cold water, but only delivers a relative

humidity of 50% at ambient temperatures.

For tracheostomy patients on high inspiratory flow rates of oxygen with tenacioussecretions or patients complaining of subjective dryness a heated device is indicated

and can be incorporated into the circuit.

Note: Condensation from heated or cold humidification should be considered

infectious waste and disposed of according to hospital policy using strict

universal precautions.

Because condensate is infectious waste, it should neverbe drained back into

the humidifier reservoir.

Humidifier


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Saline Nebulisation

The nebuliser unit converts saline into a supersaturated aerosol of liquid droplets

which penetrates the lung moistening the airways. It may be indicated in

tracheostomy patients who are mechanically ventilated, receiving oxygen therapy or

self-ventilating on air.

Saline nebulisers help to reduce the viscosity of secretions which makes them easierto remove by suction or cough.

Saline nebulising involves administration of 5 mls 0.9% sterile normal saline intothe nebuliser unit 2-4 hourly or as required.

Nebulisers must be connected to a gas source with a flow rate of 6-8 litres/minute(or follow manufacturer's guidelines).

Ensure nebulisation is given via the tracheostomy (not the face mask!). Anebuliser can be attached to tracheostomy mask or T-piece circuit.

Tracheostomy mask with

nebuliser

Heat Moisture Exchanger

Eg Thermovent, Swedish nose

The Heat and Moisture Exchanger (HME) operates passively by utilising the principle

of replication of the functions of the naso-oropharynx, by storing heat and moisture

obtained from condensation during expiration.

HMEs consists of rolls of metal gauze or a condenser element like propylene

sponge/fibre sheet/corrugated paper. It is indicated for tracheostomy patients who

are mechanically ventilated or on oxygen therapy for short periods (< 96 hours) or

who are self-ventilating on air.

Swedish nose Thermovent


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Heat Moisture

Exchanger (HME)

HMEs must be changed

every 24 hours or

earlier if waterlogged

or contaminated with

secretions.

Buchanan Bib/Foam Filter

Bibs can be used with patients who are self

ventilating and do not require oxygen

therapy. The bibs act in a similar way to aheat moisture exchange device and is

indicated for long term

tracheostomy/laryngectomy patients to

ensure the stoma/airways remain warm and

moist. Wearing the protector will help to

reduce the risk of chest problems caused by

cold, dry air, and are effective in removing

dust and dirt particles in the air helping to

reduce the risk of infection. The bib is tied

loosely around the patients neck and placed over the tracheostomy stoma. The bib

should be observed for any build up of secretions and changed daily. The manufacturer

recommends that the bibs should be washed no more than 3 times before discarding.


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Bedside equipment

All patients with a tracheostomy in situ cared for on the general wards must have spare

equipment to deal with airway emergencies immediately available.

It is important to check all equipment is available prior to the patient arriving on the ward,

and also at the beginning of every shift.

TRACHI-CASE is one of a number of commercially available kits for this purpose.

Ideally, the case will arrive with the patient if they are admitted to the ward from a Critical

Care area. If a patient is admitted from another source a box must be obtained from the

Critical Care Unit or contact the Outreach team.

This box will be sealed and include equipment needed in case of airway emergency. It

should not be opened at any other time. This box will stay at the patients bedside at all

times. If the patient is decannulated, discharged to another hospital site or dies the box

must be returned to the Critical Care Unit or the Outreach team. This box will then be

cleaned and re-used.


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The bedside emergency case should contain the following items:

Spare tracheostomy tubes: the same size and a size smaller

Tracheal dilators- sterile packed

Stitch cutter- if the tube is sewn in

10ml syringe- for cuff deflation

Scissors- to cut neck tapes in the case of emergency

Spare trachy holder

Spare trachy dressing

Catheter mount

Yankeur sucker

Other essential equipment to be available in the Critical Care area

caring for the patient with a tracheostomy

Fibreoptic intubating endoscope

Suction equipment and a selection of suction catheters including yankauer

Aintree (airway exchange) catheter

Capnography

Bag and Valve circuit (eg a Waters circuit or similar)

Facemask

Piped oxygen

Appropriate humidification system

Oral airway equipment such as a range of laryngoscopes and endotracheal tubes

should be available on the cardiac arrest trolley

Other equipment to be kept at the bedside Sterile water- for cleaning the suction tube

Clean pot for spare inner cannula

Sterile gloves- for performing deep suction

Tracheostomy dressings

Tracheostomy tapes

Large yellow bag- for clinical waste e.g. suction catheters

Nurse call bell- the patient may be unable to verbally call for help

Communication aids- the patient may not be able to verbalise

The bed-side of a tracheostomised patient should have a checklist completed at

least once every 24 hours of the above equipment.


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Equipment to be kept at the bedside of a ward patient

This list is likely to be open to local negotiation and will depend on the type of ward and its

casemix. Minimum equipment for each patient should include:

Trachicase or similar emergency trachy equipment

Cardiac arrest trolley or similar containingo Bag and Valve circuit (eg a Waters circuit or similar)

o Facemask

o Oral airway equipment such as a range of laryngoscopes and endotracheal

tubes

Suction equipment and a selection of suction catheters including yankauer

Piped oxygen

Appropriate humidification system

Sterile water- for cleaning the suction tube

Clean pot for spare inner cannula

Sterile gloves- for performing deep suction

Tracheostomy dressings & tapes

Nurse call bell- the patient may be unable to verbally call for help

Communication aids- the patient may not be able to verbalise

Clear guidance should be in place regarding where to obtain a fibreoptic endoscope and

monitoring such as Capnography in the event of an emergency.


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Tracheal Suction

Where a patient has a good cough reflex and can clear their own secretions past the

tracheostomy tube, suction should not be performed routinely or at set times and

should be performed only when the patient requires it. For example;

Viscous secretions

Reduced breath sounds

Restlessness

Sweating

Visible or audible gurgling sounds

Increased heart rate and blood pressure

Reduced air flow at stoma site during respiration

Decreased oxygen saturation levels

Inability to cough up secretions

See-saw breathing or use of intercostals muscles

Suctioning should be performed using aseptic techniques, with the patient in an upright

position and with their head in a neutral alignment. Where patients have a poor or no

cough effort suctioning should be carried out at least every 2-4 hours and documented

on the care plan. In this group of patients if no secretions are removed on the first pass

do not attempt again but wait until suctioning is due again or the patient is showing any

of the above signs.

If no secretions are removed do not increase the suction pressure above the

recommended levels as this causes trauma to the trachea. Check the patient hasadequate humidification and hydration. Ideally the maximum amount of secretions

should be removed with the minimal amount of tissue damage and hypoxemia. In the

hands of a skilled practitioner suctioning may be no more than a discomfort for the

patient. Using the incorrect technique can cause pain, choking, gagging and hypoxia.

Potential complications of suctioning:

Hypoxia,

Cardiac arrhythmias

Trauma to the tracheal mucosa.

Laryngospasm Alveoli collapse

Infection

These complications can be considerably reduced if:

Pre/post oxygenation is given, for patients who are oxygen dependant

The use of an appropriate technique with an appropriately sized suction catheter

Appropriate duration and frequency of the procedure: the procedure should last

for no longer than 10 seconds (time it takes to hold your breath).

The lowest possible suction pressure is used: no greater than 13-16 KPa or 100 -

120mmHg


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Adequate infection control measures are taken

Installation of saline to aid suctioning is not recommended. The correct size suction

catheter can be calculated by using the following formula:

Size of the tube internal diameter - 2) x 2

For example 6mm ID (6-2) x 2 = size 8 suction catheter

7mm ID (7-2) x 2 = size 10 suction catheter



Any difficulty in passing the suction catheter could be a sign that the tube is partially

blocked or misplaced and should therefore be fully investigated.

Guidelines for suctioning tracheostomies

Prior to suctioning

Assessment of vital signs/oxygen saturations

Explanation to the patient and preparation

Consider 1-2 minutes of pre-oxygenation if oxygen dependant

Hand washing

Use of apron/gloves/eye protection (goggles)

During suctioning

Infection control awareness

Accurate catheter size/design Accurate suction pressure

Continuous suction pressure on withdrawal only

Caution when inserting catheter not to cause trauma to the carina and mucosa

Accurate duration (no longer than 10 seconds)

Limit number of suction passes

Post suctioning

1-2 minutes oxygenation if oxygen dependant

Assessment of vital signs/oxygen saturations

Observe respiratory rate and pattern

Offer reassurance to the patient

Equipment needed

Suction source (wall or portable), collection container and tubing, changed every

24 hours to prevent growth of bacteria

Sterile suction catheters & gloves

A selection of non-sterile, clean boxed gloves.

Sterile bottled water (labelled suction with opening date), changed every 24

hours to prevent the growth of bacteria.

Disposable plastic apron & eye protection, e.g. goggles.


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Bactericidal alcohol handrub


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Procedure for suctioning a mini-trach is as above, however only use a black (size 10ch)

suction catheter.

When a fenestrated tracheostomy tube is in situ, insert a plain inner cannula prior to

suctioning. This prevents the suction catheter passing upwards through the fenestration(s)

and causing mucosal damage to the trachea.

Suction tubing should be changed daily or as necessary if heavily soiled but at or

when patients treatment is discontinued.

Suction unit container should be checked each shift and changed if full. If thecontainer becomes full it can affect suction pressure, which can cause unnecessary

trauma to the patient.

Plastic inner cannula should not be soaked in solutions as there is a danger that the

materials may absorb the solution and subsequently damage the equipment or the

trachea.Some types of trachy-mask (which supply oxygen to the

patient via a tracheostomy) have an opening in them to

allow suction without having to interrupt the supply of

oxygen.


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STOMA CARE

Tracheostomy stoma care aims to keep the area clean and dry, reducing the risk of skin

irritation and infection. Secretions collected above the tracheostomy tube cuff may ooze out

of the surgical incision and stoma site. The resultant wetness can promote irritation of the

skin and can lead to skin maceration and excoriation. This increased moisture may act as amedium for bacterial growth or prevent the stoma site from healing.

The tracheostomy stoma dressing should be reviewed each shift, and should be changed at

least every 24 hours. However the frequency of dressing changes will be indicated by the

amount of secretions oozing around the stoma site, therefore if the dressing is

contaminated - change it. If there is any evidence of infection swab the site and send to

microbiology.

A slim, absorbent dressing is the most appropriate - specific tracheostomy dressings will

have a keyhole design for easy placement around the tracheostomy tube. Hydrophilic,

polyurethane foam dressings e.g. LyofoamTM

or AllevynTM

are preferable as they aredesigned to absorb moisture away from the skin interface thereby reducing maceration risk.

Tracheostomy tube holders hold the tube in place as long as they are secure around the

neck one finger should slide comfortably between the neck and the holders. Check the

holder each shift and change if contaminated. Changing a stoma dressing or holder requires

two members of staff, one to hold the tracheostomy tube and the other to carry out the

dressing change. This helps to ensure that the tube is not dislodged.

After the tracheostomy tube has been removed the stoma is not sutured but left to heal;

healing time may vary but is usually between 5-7 days depending on how long the

tracheostomy tube has been in place, the general health of the patient and the procedureperformed. During the healing time the stoma should be dressed with an absorbent dressing

e.g. Lyofoam or Allevyn and secured with a transparent dressing e.g. BiocclusiveTM

or

OpsiteTM

. Do not use gauze as loose threads can be inhaled. Sleek dressing should not be

used post-decannulation. Due to its adhesive and opaque nature; it is very irritating to the

skin and encourages bacterial growth.

Tracheostomy masks should be cleaned with hot soapy water if any evidence of

contamination. Nebuliser equipment should be cleaned after every use with hot soapy water

to prevent a build up of crystals from nebulised drugs.

Guideline for changing the tracheostomy dressing and holder

Equipment needed - Prepare all equipment prior to the procedure.

Sterile powder-free gloves

Dressing pack

Normal saline 0.9%

Pre-cut keyhole dressing for example Lyofaom T

Tracheostomy tube holder

Yellow clinical waste bag

Appropriate personal protection i.e. apron, gloves and goggles

Trachi-Case (Emergency equipment) and functional suction equipment should be readilyavailable at the bedside at all times. Resuscitation equipment should always be available.


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Changing a tracheostomy tube holder


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Cleaning and changing the inner cannula

This procedure aims to remove secretions from the inner cannula to reduce the risk of potential

obstruction with sputum and reduce the risk of infection. Secretions can adhere to the internal

lumen of a tracheostomy tube and severely reduce the inner lumen diameter over time. This

potentially can increase the work of breathing and/or obstruct the patients airway.

The inner cannula should be removed and inspected at least every shift or if the patient shows any

signs of respiratory distress. It should be documented on the ICP when the tube has been cleaned.

Ensure the inner cannula is the appropriate size for the tracheostomy tube, replace with inner

cannula of same size. If a larger cannula is forced into a tracheostomy tube it will protrude through

the tip of the tracheostomy tube causing erosion of the soft mucosa of the trachea. Conversely if the

inner cannula is too small secretions may build up between the inner cannula and the outer lumen.

The inner cannula will require removal and inspection if any symptoms of respiratory distress are

evident as part of the assessment algorithm. If this does not resolve the problem, please refer to

emergency algorithm for immediate actions.

Equipment required

Trachi-Case (Emergency equipment) and functional suction equipment should be readily available at

the bedside at all times. Resuscitation equipment should also be available.

Clean and dry tracheostomy inner cannula x2 - same size as tracheostomy tube in case one

becomes contaminated

Tracheostomy sponges for cleaning

Clean container to store inner cannula when not in use

Sterile Water or saline

Bacteriacidal alcohol hand rub Powder free gloves and apron

Goggles

Yellow clinical waste bag


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Changing an Inner Tube


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Oral

hygienePatients with tracheostomies, especially those who are nil by mouth, require regular oral care due to

the reduced evaporation of oral secretions, which accumulate in the mouth. This is due to the

disruption of normal airflow during inhalation and exhalation. Patients who are able to should be

encouraged to maintain their own oral hygiene by using a toothbrush and using mouthwashes.

Incapacitated patients should have a daily assessment of their buccal mucous membranes to

observe for bacterial, viral or fungal infections, skin tears or ulceration. If any evidence of any oral

infections, treat appropriately.

Important Points

Regular oral hygiene - minimum x 2 per day but preferably every 2-4 hours

Documents

Background Informat Information for Trachy Competencies